How many missed visits before a patient is discharged?

caliotter3 · Aug 28, 2011

In this case I think it is appropriate to discharge and readmit. That is too long to be out of the loop.

paddler · Aug 28, 2011

I agree it is appropriate to discharge the patient once the physician is made aware of the problem. It seems this patient may not be homebound which would disqualify them from HH services anyway. However, often times the agency does not want to discharge too soon even if there are many missed visits because if you D/C and the patient is re-admitted prior to what would have been the end of the episode, the second admission episode is reimbursed at a lower rate. It pays off to keep them "on the books" until the end of the cert period and discharge then, rather than "prematurely" and risk having to re-admit within the 60 day time frame.

caliotter3 · Aug 28, 2011

I had a client who was hospitalized one time for a long time. The agency discharged the patient, as I recall, at the 30 day point. Then when he came home, they reopened the case. The admitting RN did not spend much time on the SOC as she was mostly referring to the original documentation and asking the nurse on duty (me) about any changes that came about as a result of the hospitalization.

nurse955 · Aug 28, 2011

the patient is been seen 1x/wk for disease teaching relating to diabetes and hypertension. During past visits, lot of time is spent on disease process, dietary choices, and complications.

I forgot to mention this is a non-pay case as the agency is trying to build a caseload for the 7 active patients required for initial medicare certification.

Do I need to inform pt that she is going to be discharged? If so, do I send a letter or document the conversation on a progress note?

paddler · Aug 28, 2011

You are supposed to give them a form called a HABN or EDN that they sign acknowledging the discharge.

KateRN1 · Aug 28, 2011

Check with your agency's policy manual, but this is my recommendation, worth every dime you've paid for it.

First step is to determine if the patient is homebound. If she is staying with her daughter to receive assistance that cannot be provided in her own home, then she is still homebound. If this is the case, then is the daughter's residence within the agency's service area and will the patient agree to visits at that home?

If it is determined that the patient is not homebound, then immediate discharge is appropriate. Keeping a non-homebound patient on the books in order to avoid a PEP is fraudulent practice. Document any and all conversations with the patient, the daughter, and physician and send a notice of discharge to her residence. If the patient left the agency's service area without notification, an EDN/NONMC or HHABN is not required, although you can read the statement on Option Box 2 and give the patient the number to call the Medicare QIO to make sure that all bases are covered. Follow up with a registered letter sent to the patient's address or the daughter's address if she will give it to you.

In any case, make sure that you are following the policies in your agency's policy book as that is what your surveyors will hold you to.

Become very familiar with the CMS guidance at CMS.gov, your regional home health intermediary's local coverage details, the Medicare Benefit Policy Manual, and your state's home health rules and regs. There are a lot of regs to keep up with. OASIS Answers publishes the OASIS Q&As quarterly that can help with OASIS issues.

nurse955 · Aug 28, 2011

the daughter residence is within the agency's service area and the patient has no problem with visits conducted at her daughter home.

Patient's visit to her daughter is strictly for relaxation and to spend time with her grandchildren; does this mean she is not homebound?

The agency owner really wants to keep this patient but she says her insurance policy only covers care provided at the patient's residence.

KateRN 1- do you have a link for OASIS Q&As quarterly

KateRN1 · Aug 29, 2011

It sounds like this is not a Medicare patient, so check with the insurer. My specialty is Medicare home care guidelines, so they may or may not apply to your patient. Although most insurers use Medicare guidelines, many have added restrictions and may not require HHABN, EDN/NOMNC, etc., which are Medicare-specific forms.

If the patient is able to easily travel between her home and her daughter's, can drive herself, or is even being left alone with the grands, she may not meet homebound criteria, but this is not something that can be determined by a stranger on the computer. Your agency will have to do the due diligence on that one. Find out what are the criteria for her insurer to determine homebound status.

OASIS Q&As: https://netforum.avectra.com/eWeb/DynamicPage.aspx?Site=OCCB&WebCode=ArticleSearch

Isabelle49 · Aug 29, 2011

the daughter residence is within the agency's service area and the patient has no problem with visits conducted at her daughter home.
Patient's visit to her daughter is strictly for relaxation and to spend time with her grandchildren; does this mean she is not homebound?
The agency owner really wants to keep this patient but she says her insurance policy only covers care provided at the patient's residence.
KateRN 1- do you have a link for OASIS Q&As quarterly

I'm not sure what your agency owner is referring to?? We often have patients who will stay a week here and a week there and then a weeks home and as long as they are in our service area, we continue to see them. I would think that while the patient is visiting a daughter, the daughter's home is the patient's home.

KateRN1 · Aug 30, 2011

Although many private insurers will conform to Medicare requirements, some have their own rules for service and this may be the case with this insurer. Medicare and Medicaid are not the only payers for home health care services and ultimately it comes down to rules of the insurer as well as internal policy and procedure.

nurse955 · Aug 31, 2011

Thank you all for your replies